Skip to main content

Acting with Client-specific Orders

Practice Standard for registered psychiatric nurses

Introduction

Standards

BCCNM limits and conditions for registered psychiatric nurse: Acting with client-specific orders


Introduction

The Registered Psychiatric Nurse: Acting with Client-specific Orders practice standards, limits, and conditions apply to registered psychiatric nurses and certified practice registered psychiatric nurses wh​​en they are acting with client-specific orders.

Acting with client-specific orders refers to registered psychiatric nurses performing activities that they are competent and allowed to perform with a client-specific order.

Registered psychiatric nurses may provide care to clients by acting with a client-specific order for an activity that is:

  1. Outlined in the Nurses (Registered Psychiatric) Regulation,
  2. In alignment with BCCNM standards, limits, and conditions,
  3. Allowed by organizational/employer policies, processes, and restrictions, and
  4. Within the registered psychiatric nurse's individual competence.

Registered psychiatric nurses need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order is required before performing an activity.

A client-specific order is an instruction or authorization given by a regulated health professional for a nurse to provide care for a specific client, whether or not the care or service includes a restricted activity or a non-restricted activity.

  • ​A consultation, referral or professional recommendation is not an order.
  • ​Registered psychiatric nurses also need to know which health professionals are authorized to give a client-specific order that they are allowed to act with.

Registered psychiatric nurses need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order is required before performing an activity.

A registered psychiatric nurse may act with a client-specific order given by:

​1.
​​An authorized health professional who is listed in the Nurses (Registered Psychiatric) Regulation as authorized to give an order for a restricted activity to be performed by a registered psychiatric nurse.
  • ​ Only these health professionals are authorized to give orders for activities listed in section 7 (restricted activities that require an order) of the Regulation[1] that allow the registered psychiatric nurse to perform that activity.
  • For registered psychiatric nurses, authorized health professionals include physicians, nurse practitioners, certified practice registered nurses, certified practice registered psychiatric nurses, dentists, midwives, naturopaths, podiatrists, and pharmacists.
​2.
​A non-listed health professional who is NOT listed in the Nurses (Registered Psychiatric) Regulation is not authorized to give orders for restricted activities in section 7 of the Regulation.[1]

  • ​ However, depending on organizational/employer policies and processes, a non-listed health professional may give orders for activities that are within the registered psychiatric nurse's autonomous scope of practice.
  • Non-listed health professionals have specialized competence within their profession's scope of practice and individual competence that allows them to assess a client and to design or recommend care to meet the client's needs.

Standards

1.
Registered psychiatric nurses require a client-specific order from an authorized health professional to perform any restricted activity listed in section 7 (restricted activities that require an order) of the Nurses (Registered Psychiatric) Regulation (to the extent the care provided is not within the activities or related limits and conditions listed in section 6 of the Nurses (Registered Psychiatric) Regulation or, as noted for certified practice registered psychiatric nurses, in Section 7.1)​​.
2.​​
Registered psychiatric nurses acting with a client-specific order ensure the ordered activity is:

a.
Within the scope of practice as set out in the Nurses (Registered Psychiatric) Regulation,

b.
Consistent with standards, limits and conditions established by BCCNM,

c.
Consistent with organizational/employer policies, processes, and restrictions, and 

d.
Within their individual competence.
3.
Registered psychiatric nurses acting with a client-specific order ensure that they have the competence to:

a.
Perform the activity safely and ethically,

b.
    Identify potential risks of the activity to the client and how to minimize those risks,

c.
    Manage the intended outcomes of the activity, and

d.
Recognize unintended outcomes of the activity and implement a plan for dealing with these unintended outcomes.
4.

Before performing an activity with a client-specific order, registered psychiatric nurses consider applicable employer/organizational policies, processes, and resources, and other relevant human and system factors that may impact their ability to:

a.
    Perform the activity competently and safely within their practice setting, and

b.
To manage intended and unintended outcomes of the activity.
5.
Registered psychiatric nurses perform advanced activities with a client-specific order only when they have obtained the additional education, training, and/or clinical experience needed to gain and maintain the competence to perform the activity safely.
6.
Registered psychiatric nurses acting with a client-specific order ensure that the order:

a.
    Is client-specific, 

b.
Is clear and complete,

c.
Is documented, legible, dated and signed with a written/electronic signature, and

d.
Contains enough information for the nurse to carry it out safely.
7.

Registered psychiatric nurses accept a verbal or telephone client-specific order only when there is no reasonable[2] alternative, according to organizational/employer policies and processes, and when doing so is in the best interest of the client. Nurses repeat the client-specific order back to the ordering health professional to confirm its accuracy and promptly document the order.
8.
Registered psychiatric nurses conduct assessments to ensure that the client's condition continues to warrant the activity before acting with a client-specific order.
9.
Registered psychiatric nurses may not change or cancel a client-specific order given by an authorized health professional when the activity is outside of the nurse's autonomous scope of practice or the nurse's individual competence.
10.
Registered psychiatric nurses communicate and collaborate with the health professional (or their delegate) who gave the client-specific order, follow organizational/employer policies and processes, take action as needed, and document in the client record, when:

a.
The ordered activity may no longer be appropriate because the client's condition, needs or wishes have changed (e.g., to 'hold' the order),

b.
They are not able to carry out a client-specific order, 

c.
The client-specific order does not appear to consider a client's individual characteristics, values/beliefs, and preferences, 

d.
The client-specific order does not appear to reflect current evidence or be in the best interest of the client,

e.
They change or cancel a client-specific order for activities that are within their autonomous scope of practice, or

f.
The safeguards and resources are not available to manage the outcomes of performing the activity, including reasonably foreseeable unintended outcomes. 
11.

Registered psychiatric nurses follow the standards for Acting within Autonomous Scope of Practice when they change or cancel a client-specific order that is within their autonomous scope of practice and individual competence. 
12.
Registered psychiatric nurses are responsible and accountable for any changes or cancellations they make to a client-specific order that is within their autonomous scope of practice and individual competence.
13.
Registered psychiatric nurses obtain a client-specific order to perform an activity or provide care or a service that is within their autonomous scope of practice when:

a.
It is required by organizational/employer policies, processes, or restrictions, 

b.
There are insufficient organizational/employer supports, processes and resources in place (such as decision support tools or clinical practice documents) to enable the nurse to meet BCCNM standards, limits, or conditions related to the activity, ca​re or service, or

c.

The nurse does not have the individual competence to make a nursing diagnosis or carry out an assessment to determine whether the client would benefit from the activity, care, or service, but is competent to carry out the activity. 
14.
Registered psychiatric nurses ONLY act with a client-specific order from a non-listed health professional when: 

a.
The activity is within the nurse's autonomous scope of practice,

b.
The nurse is able to meet BCCNM standards, limits, or conditions related to the activity, 

c.
The activity is within the nurse's individual competence, and 

d.
Organizational/employer policies, and processes exist that: 


i.   Clarify the accountability and responsibility of the nurse and the non-listed health professional, and 

      ii. Outline the requirements for the non-listed health professional to complete an assessment and to ensure that the ordered activity is in the best interest of the client.


BCCNM limits and conditions for registered psychiatric nurse



​​Activity BCCNM Limits Conditions for Registered Psychiatric Nurse: Acting with Client-specific Orders​​
1.​ Use of restraint and seclusion

a. When using restraint or seclusion[3] interventions, registered psychiatric nurses must follow applicable legislation[4] specific to their practice setting.

b. When using mechanical restraint[5] or seclusion interventions with clients certified under the Mental Health Act, registered psychiatric nurses must act with a client-specific order from an authorized health professional, except in an emergency situation.

​2.

Perform wound care

 

a. Registered psychiatric nurses must successfully complete additional education before carrying out:
i.  Suturing of skin lacerations
ii. Conservative sharp wound debridement
iii. Negative pressure wound therapy
iv. Biological debridement therapy
v. Compression therapy
3.​ Peritoneal dialysis

a. Registered psychiatric nurses must successfully complete additional education to carry out peritoneal dialysis.

4.​

Administer by inhalation:

  • Do not administer nitrous oxide

a. Registered psychiatric nurses must not administer nitrous oxide.

​5.
Care of clients on mechanical ventilation

​a. Registered psychiatric nurses must successfully complete additional education to care for clients on mechanical ventilation

​6.

Administer a solution by irrigation:

  • irrigate a bladder

​a. Registered psychiatric nurses must act with a client-specific order from an authorized health professional to irrigate a bladder.

7.​

Perform venipuncture and establish intravenous access

 

a. Registered psychiatric nurses must successfully complete additional education to carry out venipuncture and to establish intravenous access.

b. Registered psychiatric nurses are limited to using short peripheral venous devices to establish intravenous access.

c. Registered psychiatric nurses are limited to taking blood with short devices or from existing peripheral venous access devices.

​8.

Perform venipuncture:

  • Do not take blood for donation
a.      At this time registered psychiatric nurses must not take blood for the purpose of donation.
9.​

Administer a substance by parenteral instillation:

  • blood and blood products

a. Registered psychiatric nurses are limited to administering blood and blood products to clients with stable and predictable physiological health.

b. Registered psychiatric nurses must successfully complete additional education to administer blood or blood products.

​10.

Administer a substance by central venous access devices (CVAD)*

*This may also be referred to as a central venous device (CVD) or central venous catheter (CVC).

​a. Registered psychiatric nurses must successfully complete additional education to administer a substance via central venous access devices.
​11.

Administer a substance:

  • Do not administer substances by these routes

a. Registered psychiatric nurses must not administer substances via:

i.   Intrathecal spaces, 
 ii. epidural spaces, 
iii.  perineural spaces.
12.​

Administer a substance:

  • Do not induce general anesthesia or maintain general anesthetic agents

a. Registered psychiatric nurses must not induce general anesthesia or maintain general anesthetic agents.
 

​13.

Administer a substance:

  • Do not administer radiopaque dyes by parenteral instillation

a. Registered psychiatric nurses must not administer radiopaque dyes via parenteral instillation

​14.
Care of clients on hemodialysis

a. Registered psychiatric nurses must successfully complete additional education to carry out hemodialysis.

​15.

Put an instrument or device beyond the point in the nasal passages where they narrow:

  • nasogastric tubes (NG)

a. Registered psychiatric nurses are limited to re-inserting previously established nasogastric tubes (e.g., replacing a blocked tube) within their autonomous scope of practice (without an order).

b. Initial insertion of a nasogastric tube requires a client-specific order from an authorized health professional.

​16.

Put an instrument or device beyond the pharynx:

  • Do not perform endotracheal intubation

​a. Registered psychiatric nurses must not carry out endotracheal intubation.

​17.

Put an instrument or device, or finger beyond the labia majora:

  • pelvic exams
  • cervical cancer screening

Registered psychiatric nurses who carry out pelvic exams or cervical cancer screening must:

i.  suc​cessfully complete additional education, and

ii. possess competencies (BCCDC: Competencies for Pelvic Examination) outlined in Core Nursing Practice Competencies for Pelvic Exams (for Registered Nurses) established by the Provincial Health Services Authority (PHSA) or equivalent approved by their employer.

18.​

Apply electricity:

  • Do not apply electricity for the purpose of affecting activity of the nervous system except transcutaneous electrical nerve stimulation (TENS)

a. Registered psychiatric nurses must not apply electricity for the purpose of affecting activity of the nervous system other than TENS (Transcutaneous electrical nerve stimulation).
 

​19.

Apply electricity:

  • Do not perform manual defibrillation

a. Registered psychiatric nurses must not apply electricity using a manual defibrillator

20.​

Administer medications:

  • Do not administer medications by these routes

 

a. Registered psychiatric nurses must not administer medication via:

i.  Intrathecal route,
ii. Epidural route,
iii. intraosseous route,
iv. perineural route.
​21.

dminister medications:

  • central venous access devices (CVAD)*

*This may also be referred to as a central venous device (CVD) or central venous catheter (CVC).

a. Registered psychiatric nurses must successfully complete additional education to administer medication via central venous access devices.

22.​

Administer medications:

  • Do not induce general anesthesia or maintain general anesthetic agents

a. Registered psychiatric nurses must not induce general anesthesia or maintain general anesthetic agents.

23.​

Administer medications:

  • procedural sedation
​a. Registered psychiatric nurses may induce procedural sedation with a client-specific order from an authorized health professional.
​24.

Administer medications:

  • experimental medications

(Drug Schedules Regulation)

a. Registered psychiatric nurses may administer experimental medications not yet listed in any drug schedule as part of a formal research program.

​25.

Compound, dispense, or administer medication:

  • Do not compound, dispense, or administer Schedule I drugs for the purpose of medical assistance in dying (MAiD)

    (Drug Schedules Regulation)

a. Registered psychiatric nurses must not compound, dispense or administer schedule I drugs for the purpose of medical assistance in dying.

​26.

Compound, dispense, or administer Schedule II drugs

(Drug Schedules Regulation)

a. Registered psychiatric nurses require a client-specific order from an authorized health professional to compound, dispense or administer Schedule II medications to treat a disease or disorder.

b. Registered psychiatric nurses who administer Schedule II drugs intravenously via a peripheral venous access device must either:

i.  follow an employer approved decision support tool

OR

ii. act with a client-specific order from an authorized health professional.

c. Registered psychiatric nurses who administer medication via central venous access devices must:

i.  act with a client-specific order from an authorized health professional, and

​ii. successfully complete additional education to administer medication via central venous access devices.

27.   Medical aesthetics[6]

a. Registered psychiatric nurses successfully complete additional education before providing medical aesthetic procedures.

b. Registered psychiatric nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so:

i.  with a client-specific order from an authorized health professional, and

ii. when the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation.

​​​​​​​

​​Glossary​

Additional education: Additional education is structured education (e.g., workshop, course, program of study) designed for the nurse to attain the competencies required to carry out a specific activity. Additional education:

  • builds on the entry-level competencies
  • identifies the competencies expected of learners on completion of the education,
  • includes both theory and application to practice, and
  • includes an objective evaluation of learners' competencies on completion of the education.

Advanced activities: Activities that are within a nurse's scope of practice but require additional education, training and/or clinical experience that build on the foundational knowledge, skills, and judgement attained during entry-level nursing education.

Competence: The integration and application of current knowledge, skills, attitudes, and judgment required to perform safely, ethically, and appropriately within an individual's practice.

Competencies: The knowledge, skills, attitudes, and judgment required to provide safe, competent, and ethical care within an individual's practice or in a designated role or setting.

Decision support tools (DSTs): Evidence-based documents used by nurses to support clinical judgment and decision-making by guiding the assessment, diagnosis and treatment of client-specific clinical problems. DSTs come in various forms and are created by organizations or specialists in a specific area of health care.​

​​Foot​​​notes​

[1]  To the extent the activity is not within the activities or related limits and conditions listed in section 6 of the Regulation.

[2]  “Reasonable" refers to the common understanding that registrants of BCCNM would have as to what is appropriate in the situation.

[3]  Seclusion is a physical intervention that involves containing a client in a room from which free exit is denied (Government of BC, Ministry of Health, 2012, Secure rooms and seclusion standards and guidelines: A literature and evidence review).

[4]  If restraint and seclusion is not done with legislative authority, the act may be an assault. Some examples of provincial and federal legislation which may be applicable to the use of restraint and seclusion are the Residential Care Regulation Community Care and Assisted Living ActMental Health Act, Corrections Act, the Criminal Code of Canada and Corrections and Conditional Release Act.

[5]  Mechanical restraint involves the use of devices to partially or totally restrict the client's movements.

[6]  “Medical aesthetics" refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Registered Psychiatric) Regulation) and are primarily intended to alter or restore a person's appearance​.

​​​Need help or support?​

For further guidance on understanding and applying the standards of practice, contact our team by completing the Standards Support intake form.​

900 – 200 Granville St
Vancouver, BC  V6C 1S4
Canada

info@bccnm​.ca
604.742.6200​
​Toll-free 1.866.880.7101 (within Canada only) ​


We acknowledge the rights and title of the First Nations on whose collective unceded territories encompass the land base colonially known as British Columbia. We give specific thanks to the hən̓q̓əmin̓əm̓ speaking peoples the xʷməθkʷəy̓əm (Musqueam) and sel̓íl̓witulh (Tsleil-Waututh) Nations and the Sḵwx̱wú7mesh-ulh Sníchim speaking Peoples the Sḵwx̱wú7mesh Úxwumixw (Squamish Nation), on whose unceded territories BCCNM’s office is located. We also give thanks for the medicines of these territories and recognize that laws, governance, and health systems tied to these lands and waters have existed here for over 9000 years.

We also acknowledge the unique and distinct rights, including rights to health and wellness, of First Nations, Inuit​ and Métis peoples from elsewhere in Canada who now live in British Columbia. As leaders in the settler health system, we acknowledge our responsibilities to these rights under international, national, and provincial law.​